Antipsychotic drugs guidelines

As with antidepressant therapy, reversal of psychosis is often gradual and may occur over several weeks to several months. Guidelines for the acute use of antipsychotic drugs are summarized in Table 4— 2 usual dosages for each of the commonly used antipsychotic drugs are summarized in Table 4—1. 

The 2004 Practice Guideline for the Treatment of Patients With Schizophrenia recommends indefinite maintenance treatment for patients who have had at least two episodes of psychosis within 5 years or who have had multiple previous episodes (Lehman et al. 2004). Maintenance therapy should involve the lowest possible doses of antipsychotic drugs, and patients should be monitored closely for symptoms of relapse. If the patient is compliant with treatment, oral medications are usually sufficient. However, if the patient s treatment history suggests that the patient may not reliably take daily oral medication, a long-acting depot preparation may be indicated. 

Efficacy in short-term treatment. From studies in adult schizophrenia, it is evident that clozapine treatment has at least the same or superior antipsychotic effect, compared to typical antipsychotics. In some studies, clozapine was superior with regard to symptom reduction in severe and acute schizophrenic patients. As the guidelines do not allow the use of clozapine as a first-choice drug, most patients have been treated before with at least two atypical or typical antipsychotics. Only one controlled trial has assessed the efficacy of clozapine in child and adolescent psychiatry. In this study (Kumra et ah, 1996), clozapine was found to be superior to haloperidol in all measures of psychosis, and showed a striking superiority for both positive and negative symptoms. 

Note. None of these medications have FDA indication for the treatment of Alzheimer s disease. The literature and practice guidelines support the use of these medications for specific target symptoms. The FDA has issued a black box warning regarding the use of certain antipsychotic medications in the elderly, especially haloperidol, olanzapine, and risperidone. The warning notes that the use of these drugs is associated with an increase in death rates when used by the elderly patients with dementia. 

A wide variety of medications have been found to sometimes be helpful in self-injurious behavior. Those that have been found to sometimes be helpful in self-injurious behavior in the context of a personality disorder, including MAO inhibitors, SSRIs, carbamazepine, lithium, antipsychotics, and benzodiazepines. The choice of medication should be based on the associated features present. Thus, when depressive features are present, try an SSRI when there are symptoms of atypical depression and rejection sensitivity, an MAOI and when psychotic features are present, an antipsychotic. This is an area where there are no clear guidelines for medication use and no guarantee of effectiveness. However, using trial and error, one can often find a drug that has significant benefit. 

Use alone or in combination with other drugs (e.g., lithium, valproate, antipsychotics) for the acute and long-term maintenance treatment of mania or mixed episodes for bipolar I disorder. APA guidelines recommend reserving it for patients unable to tolerate or who have inadequate response to lithium or valproate. 

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